Drugs for Open-Angle Glaucoma

full update February 2025

The following chart has info on available glaucoma meds, including cost, select side effects, mechanism of action, and dosing frequency. For general information on glaucoma pharmacotherapy, see footnote c.

Drug	Approximate Cost^a	Select Side Effects^1,3,7,10	Comments
*Prostaglandin analogs*
Bimatoprost 0.01% Lumigan (US), Lumigan RC (Canada)	US: $260/2.5 mL, $530/5 mL, $790/7.5 mL Canada: $70/5 mL, $100/7.5 mL	Allergic Reactions Anterior uveitis Cystoid macular edema Darkening of eyelid, eyelashes, and iris Eye redness (lowest risk with latanoprost²), stinging, and itching Foreign body sensation Herpes virus activation Increased and/or misdirected eyelash growth Keratitis Orbital soft tissue changes Ptosis	Role: first-line due to efficacy, tolerability, and once-daily dosing.¹ Most effective drugs for IOP reduction (25% to 33%).^1,2 All prostaglandin analogs are similarly effective.² MOA: increased aqueous humor outflow¹ Usual dosing frequency: once daily in the evening³ Avoid in: macular edema, history of herpetic keratitis, active uveitis¹ Latanoprostene bunod is metabolized to the active moieties latanoprostic acid and nitric oxide.They increase aqueous humor outflow via different mechanisms. Latanoprostene bunod does not reduce IOP much more than latanoprost alone.⁴
Bimatoprost0.03% (Canada) Vistitan, Zimed PF	Vistitan: $50/5 mL Zimed PF: $60.5 mL
Latanoprost0.005% Xalatan, generics	US: $10/2.5 mL Canada: $10/2.5 mL
Latanoprost 0.005% preservative-free Iyuzeh (US), Monoprost (Canada)	US: $320/30 doses Canada: $20/30 doses
Latanoprost/Netarsudil (US) Rocklatan0.005%/0.02%	US: $350/2.5 mL
Latanoprost/Timolol (Canada) Xalacom0.005%/0.5%, generics	Canada: $10/2.5 mL
Latanoprostene bunod 0.024% Vyzulta	US: $260/2.5 mL, $520/5 mL Canada: $30/5 mL
Tafluprost 0.0015%. (US) Zioptan, generics	US: $160/30 doses
Travoprost 0.003% (Canada) Izba	Canada: $20/5 mL
Travoprost 0.004%, Travatan Z, generics	US: $80/2.5 mL, $160/5 mL Canada: $45/5 mL
Travoprost/Timolol (Canada) DuoTrav PQ 0.004%/0.5%, generics	Canada: $50/5 mL
*Beta-Blockers*
Betaxolol 0.5% solution (US)	US: $50/5 mL; $90/10 mL, $140/15mL	Allergic reactions Bradycardia Bronchospasm Blurred vision Corneal anesthesia Exercise intolerance Eye irritation (highest risk with betaxolol), dryness, redness Depression Hypotension Impotence Keratitis Ptosis	Role: second-line or adjunct.^7,8 Efficacy: 20% to 25% IOP reduction.¹ MOA: decreased aqueous humor production¹ Usual dosing frequency: once daily in the morning, to BID.¹ Avoid in: severe COPD (nonselective agents), asthma (nonselective agents), acute heart failure, bradycardia, second- or third-degree heart block^1,3 Could in theory mask hypoglycemia symptoms.⁵ Betaxolol is beta-1 selective, but not as effective as nonselective agents.^1,2 Betaxolol 0.25% suspension is as effective as the 0.5% solution and is better tolerated.⁸ Ophthalmic administration of beta-blockers can result in significant blood levels.For example, one drop of timolol 0.5% in each eye can equal as much as 10 mg of oral timolol.⁶See footnote c for information on administration techniques to limit systemic absorption.
Betaxolol 0.25% suspension Betoptic S	US: $610/15 mL, $410/10 mL Canada: $15/5 mL
Carteolol1% (US)	US: $15/5 mL, $25/10 mL, $35/15 mL
Levobunolol (US) Betagan 0.25%, 0.5% (generic only)	US: $20/5 mL (either strength)
Timolol hemihydrate (US) Betimol 0.25%, 0.5% (generic available)	US: $150/5 mL (Betimol 0.25%); 0.5% (generic): $110/5 mL, $210/10 ml, $290/15 mL
Timolol maleate See Prostaglandins, above, for combo products Xalacom and DuoTrav PQ.
Istalol (US) 0.5%, generics	US: $130/2.5 mL, $240/5 mL
Timoptic 0.25%, 0.5%, generics	US: <$5/5 mL^b (0.25%), <$10/5 mL^b (0.5%); Canada: $25/10 mL (0.25%), <$10/5 mL (0.5%), $15/10 mL (0.5%)
Timoptic in Ocudose (US) 0.25%. 0.5%, generics	US: $400/60 doses (0.25%), $210/60 doses (0.5%)
Timoptic XE gel forming solution 0.25%, 0.5%, generics	US: $180/5 mL (0.25%), $190/5 mL (0.5%); Canada: $20/5 mL (0.25%, 0.5%)
Timolol/Brimonidine Combigan 0.5%/0.2%, generics	US: $100/5 mL, $200/10 mL, $330/15 mL Canada: $25/10 mL
Timolol/Brinzolamide (Canada) Azarga 0.5%/1%	Canada: $20/5 mL
Timolol/Dorzolamide 0.5%/2%, Cosopt, Cosopt PF (US), generics; Cosopt Preservative-Free (Canada)	US: $30/10 mL; $120/60 doses (preservative-free) Canada: $20/10 mL; $50/60 doses (preservative-free)
*Carbonic Anhydrase Inhibitors*
Acetazolamide (oral) 125 mg tablet (US), 250 mg tablet; 500 mg extended-relase capsule (US)	500 mg ER BID dose or 250 mg IR QID dose: US: $80/30 days Canada: $20/30 days (IR)	Topical: Allergic dermatitis/ conjunctivitis Corneal edema Irritation of eye Keratitis Bad taste Oral: Anorexia Blood dyscrasias Depression Diarrhea Diuresis GI side effects Hypokalemia Hyopnatremia Kidney stones Malaise Metabolic acidosis Metallic taste Paresthesia Stevens-Johnson syndrome Weakness	Role: second or third-line, usually as part of combination therapy (topicals).^1,7Oral agents are usually reserved for short-term use (e.g., prior to surgery or for acute increases in IOP).⁷ Efficacy: 20% to 30% IOP reduction (oral); 15% to 20% IOP reduction (topical)¹ Do not combine orals and topicals; toxicity may be increased without additive efficacy.⁸ MOA: decreased aqueous humor production¹ Usual dosing frequency: BID to TID (topical);⁸once daily to QID (oral)³ Avoid orals in: hypokalemia, hyponatremia, severe liver or kidney impairment, sulfonamide allergy, kidney stones^1,3 Avoid topicals in: severe kidney impairment, sulfonamide allergy^1,3
Brinzolamide1% Azopt1%, generics (US) (See Beta-Blockers section for combo product Azarga [Canada])	US: $300/10 mL, $450/15 mL Canada: $20/5 mL
Brinzolamide/Brimonidine Simbrinza 1%/0.2%	US: $210/8 mL Canada: $50/10 mL
Dorzolamide 2% Trusopt, generics Trusopt Preservative-Free (Canada) (See Beta-Blockers section for combo products Cosopt, Cosopt PF [US], Cosopt Preservative-Free [Canada])	US: $20/10 mL Canada: <$10/5 mL; $80/60 doses (preservative-free)
Methazolamide (oral)	50 mg BID dose: US: $260/30 days Canada: $40/30 days
*Alpha-2 Agonists*
Apraclonidine 0.5% Iopidine (generics [US])	US: $60/5 mL; $130/10 mL Canada: $30/5 mL	Allergic dermatitis/ conjunctivitis Anterior uveitis Topical allergic reactions (more common with apraclonidine⁸) Dizziness Dry mouth and nose Fatigue Headache Hypotension Lid retraction Somnolence	Role: second-line (brimonidine);⁸short-term adjunctive therapy (apraclonidine).^1,3Note that apraclonidine 1% is not indicated for glaucoma.³ Apraclonidine use is limited by tachyphylaxis.⁸ Efficacy: 20% to 25% IOP reduction (brimonidine > apraclonidine).^1,2 Alphagan P and Alphagan have different preservatives (Purite and BAK, respetively).⁸ Purite enhances brimonidine eye penetration and is less irritating than BAK.⁸ MOA: initial reduction in aqueous humor production, then increased aqueous humor outflow³ Usual dosing frequency: TID³ Avoid: use in children, use with a monoamine oxidase inhibitor¹⁰
Brimonidine Alphagan 0.2% (Canada), generics Alphagan P0.1% (US only), 0.15%, generics (See Carbonic Anhydrase Inhibitors section for combo product Simbrinza. See Beta-Blockers section for combo product Combigan)	Alphagan 0.2% generic US ~$10 (5, 10, 15 mL) Canada: $<10/5 mL, $10/10 mL Alphagan P 0.1% generic US: $160/5 mL, $320/10 mL, $470/15 mL Alphagan P 0.15% generic US: $140/5 mL, $280/10 mL, $430/15 mL Canada: $10/5 mL, $20/10 mL
*Parasympathomimetics*
Echothiophate Phospholine Iodide (US)	US: $2,861.18/5 mL	Brow ache Conjunctivitis Increased lacrimation Myopia with blurred vision Retinal tears or detachment	Role: last-line.⁸ Efficacy: 20% to 25% IOP reduction¹ MOA: increased aqueous humor outflow¹ Usual dosing frequency: once every-other-day to BID (echothiophate); QID (pilocarpine)⁸ Avoid in: irits, uveitis³
Pilocarpine generics 1%, 2%, 4% (US); Isopto-Carpine 2% (Canada)	US: $60/15 mL (1%, 2%), $110/15 mL (4%) Canada: <$10/15 mL
*Rho Kinase (ROCK) Inhibitors*
Netarsudil 0.02% (US) Rhopressa (See Prostaglandin analogs section for combo product Rocklatan.)	US: $130/2.5 mL	Blurred vision Conjunctival hemorrhage and redness Corneal haze and verticillata Keratitis Pain with instillation Tearing	Role: adjunct.¹⁰ Efficacy: 25% to 30% IOP reduction¹⁰Most effective in patients with lower pre-treatment IOP (<25 mmHg).⁹ MOA: increased aqueous humor outflow³ Usual dosing frequency: once daily in the evening³ Discontinuation due to adverse effects greater than with timolol or latanoprost.¹⁰

Drug

Approximate Cost^a

Select Side Effects^1,3,7,10

Comments

Prostaglandin analogs

Bimatoprost 0.01%

Lumigan (US), Lumigan RC (Canada)

US: $260/2.5 mL,
$530/5 mL, $790/7.5 mL

Canada: $70/5 mL, $100/7.5 mL

Allergic Reactions
Anterior uveitis
Cystoid macular edema
Darkening of eyelid, eyelashes, and iris
Eye redness (lowest risk with latanoprost²), stinging, and itching
Foreign body sensation
Herpes virus activation
Increased and/or misdirected eyelash growth
Keratitis
Orbital soft tissue changes
Ptosis

Role: first-line due to efficacy, tolerability, and once-daily dosing.¹
Most effective drugs for IOP reduction (25% to 33%).^1,2 All prostaglandin analogs are similarly effective.²
MOA: increased aqueous humor outflow¹
Usual dosing frequency: once daily in the evening³
Avoid in: macular edema, history of herpetic keratitis, active uveitis¹
Latanoprostene bunod is metabolized to the active moieties latanoprostic acid and nitric oxide.They increase aqueous humor outflow via different mechanisms. Latanoprostene bunod does not reduce IOP much more than latanoprost alone.⁴

Bimatoprost0.03% (Canada)

Vistitan, Zimed PF

Vistitan: $50/5 mL

Zimed PF: $60.5 mL

Latanoprost0.005%

Xalatan, generics

US: $10/2.5 mL

Canada: $10/2.5 mL

Latanoprost 0.005% preservative-free
Iyuzeh (US), Monoprost (Canada)

US: $320/30 doses

Canada: $20/30 doses

Latanoprost/Netarsudil (US)

Rocklatan0.005%/0.02%

US: $350/2.5 mL

Latanoprost/Timolol (Canada)

Xalacom0.005%/0.5%, generics

Canada: $10/2.5 mL

Latanoprostene bunod 0.024%

Vyzulta

US: $260/2.5 mL, $520/5 mL Canada: $30/5 mL

Tafluprost 0.0015%. (US)

Zioptan, generics

US: $160/30 doses

Travoprost 0.003% (Canada)

Izba

Canada: $20/5 mL

Travoprost 0.004%,

Travatan Z, generics

US: $80/2.5 mL, $160/5 mL

Canada: $45/5 mL

Travoprost/Timolol (Canada)

DuoTrav PQ 0.004%/0.5%, generics

Canada: $50/5 mL

Beta-Blockers

Betaxolol 0.5% solution (US)

US: $50/5 mL; $90/10 mL, $140/15mL

Allergic reactions
Bradycardia
Bronchospasm
Blurred vision
Corneal anesthesia
Exercise intolerance
Eye irritation (highest risk with betaxolol), dryness, redness
Depression
Hypotension
Impotence
Keratitis
Ptosis

Role: second-line or adjunct.^7,8
Efficacy: 20% to 25% IOP reduction.¹
MOA: decreased aqueous humor production¹
Usual dosing frequency: once daily in the morning, to BID.¹
Avoid in: severe COPD (nonselective agents), asthma (nonselective agents), acute heart failure, bradycardia, second- or third-degree heart block^1,3
Could in theory mask hypoglycemia symptoms.⁵
Betaxolol is beta-1 selective, but not as effective as nonselective agents.^1,2
Betaxolol 0.25% suspension is as effective as the 0.5% solution and is better tolerated.⁸
Ophthalmic administration of beta-blockers can result in significant blood levels.For example, one drop of timolol 0.5% in each eye can equal as much as 10 mg of oral timolol.⁶See footnote c for information on administration techniques to limit systemic absorption.

Betaxolol 0.25% suspension

Betoptic S

US: $610/15 mL, $410/10 mL

Canada: $15/5 mL

Carteolol1% (US)

US: $15/5 mL, $25/10 mL,
$35/15 mL

Levobunolol (US)

Betagan 0.25%, 0.5% (generic only)

US: $20/5 mL (either strength)

Timolol hemihydrate (US)

Betimol 0.25%, 0.5% (generic available)

US: $150/5 mL (Betimol 0.25%);

0.5% (generic): $110/5 mL, $210/10 ml, $290/15 mL

Timolol maleate

See Prostaglandins, above, for combo products Xalacom and DuoTrav PQ.

Istalol (US) 0.5%, generics

US: $130/2.5 mL, $240/5 mL

Timoptic
0.25%, 0.5%, generics

US: <$5/5 mL^b (0.25%),
<$10/5 mL^b (0.5%); Canada: $25/10 mL (0.25%), <$10/5 mL (0.5%), $15/10 mL (0.5%)

Timoptic in Ocudose (US)

0.25%. 0.5%, generics

US: $400/60 doses (0.25%), $210/60 doses (0.5%)

Timoptic XE gel forming solution 0.25%, 0.5%, generics

US: $180/5 mL (0.25%),
$190/5 mL (0.5%); Canada: $20/5 mL (0.25%, 0.5%)

Timolol/Brimonidine

Combigan 0.5%/0.2%, generics

US: $100/5 mL, $200/10 mL, $330/15 mL

Canada: $25/10 mL

Timolol/Brinzolamide (Canada)

Azarga 0.5%/1%

Canada: $20/5 mL

Timolol/Dorzolamide 0.5%/2%,

Cosopt, Cosopt PF (US), generics;

Cosopt Preservative-Free (Canada)

US: $30/10 mL; $120/60 doses (preservative-free)

Canada: $20/10 mL;
$50/60 doses (preservative-free)

Carbonic Anhydrase Inhibitors

Acetazolamide (oral)

125 mg tablet (US), 250 mg tablet; 500 mg extended-relase capsule (US)

500 mg ER BID dose or

250 mg IR QID dose:

US: $80/30 days

Canada: $20/30 days (IR)

Topical:

Allergic dermatitis/
conjunctivitis
Corneal edema
Irritation of eye
Keratitis
Bad taste

Oral:

Anorexia
Blood dyscrasias
Depression
Diarrhea
Diuresis
GI side effects
Hypokalemia
Hyopnatremia
Kidney stones
Malaise
Metabolic acidosis
Metallic taste
Paresthesia
Stevens-Johnson syndrome
Weakness

Role: second or third-line, usually as part of combination therapy (topicals).^1,7Oral agents are usually reserved for short-term use (e.g., prior to surgery or for acute increases in IOP).⁷
Efficacy: 20% to 30% IOP reduction (oral); 15% to 20% IOP reduction (topical)¹
Do not combine orals and topicals; toxicity may be increased without additive efficacy.⁸
MOA: decreased aqueous humor production¹
Usual dosing frequency: BID to TID (topical);⁸once daily to QID (oral)³
Avoid orals in: hypokalemia, hyponatremia, severe liver or kidney impairment, sulfonamide allergy, kidney stones^1,3
Avoid topicals in: severe kidney impairment, sulfonamide allergy^1,3

Brinzolamide1%

Azopt1%, generics (US)

(See Beta-Blockers section for combo product Azarga [Canada])

US: $300/10 mL, $450/15 mL

Canada: $20/5 mL

Brinzolamide/Brimonidine

Simbrinza 1%/0.2%

US: $210/8 mL

Canada: $50/10 mL

Dorzolamide 2%

Trusopt, generics

Trusopt Preservative-Free (Canada)

(See Beta-Blockers section for combo products Cosopt, Cosopt PF [US], Cosopt Preservative-Free [Canada])

US: $20/10 mL

Canada: <$10/5 mL; $80/60 doses (preservative-free)

Methazolamide (oral)

50 mg BID dose:

US: $260/30 days

Canada: $40/30 days

Alpha-2 Agonists

Apraclonidine 0.5%

Iopidine (generics [US])

US: $60/5 mL; $130/10 mL

Canada: $30/5 mL

Allergic dermatitis/
conjunctivitis
Anterior uveitis
Topical allergic reactions (more common with apraclonidine⁸)
Dizziness
Dry mouth and nose
Fatigue
Headache
Hypotension
Lid retraction
Somnolence

Role: second-line (brimonidine);⁸short-term adjunctive therapy (apraclonidine).^1,3Note that apraclonidine 1% is not indicated for glaucoma.³
- Apraclonidine use is limited by tachyphylaxis.⁸
Efficacy: 20% to 25% IOP reduction (brimonidine > apraclonidine).^1,2
Alphagan P and Alphagan have different preservatives (Purite and BAK, respetively).⁸ Purite enhances brimonidine eye penetration and is less irritating than BAK.⁸
MOA: initial reduction in aqueous humor production, then increased aqueous humor outflow³
Usual dosing frequency: TID³
Avoid: use in children, use with a monoamine oxidase inhibitor¹⁰

Brimonidine

Alphagan 0.2% (Canada), generics

Alphagan P0.1% (US only), 0.15%, generics

(See Carbonic Anhydrase Inhibitors section for combo product Simbrinza. See Beta-Blockers section for combo product Combigan)

Alphagan 0.2% generic

US ~$10 (5, 10, 15 mL)

Canada: $<10/5 mL, $10/10 mL

Alphagan P 0.1% generic

US: $160/5 mL, $320/10 mL, $470/15 mL

Alphagan P 0.15% generic

US: $140/5 mL, $280/10 mL, $430/15 mL

Canada: $10/5 mL, $20/10 mL

Parasympathomimetics

Echothiophate

Phospholine Iodide (US)

US: $2,861.18/5 mL

Brow ache
Conjunctivitis
Increased lacrimation
Myopia with blurred vision
Retinal tears or detachment

Role: last-line.⁸
Efficacy: 20% to 25% IOP reduction¹
MOA: increased aqueous humor outflow¹
Usual dosing frequency: once every-other-day to BID (echothiophate); QID (pilocarpine)⁸
Avoid in: irits, uveitis³

Pilocarpine

generics 1%, 2%, 4% (US);

Isopto-Carpine 2% (Canada)

US: $60/15 mL (1%, 2%), $110/15 mL (4%)

Canada: <$10/15 mL

Rho Kinase (ROCK) Inhibitors

Netarsudil 0.02% (US)

Rhopressa

(See Prostaglandin analogs section for combo product Rocklatan.)

US: $130/2.5 mL

Blurred vision
Conjunctival hemorrhage and redness
Corneal haze and verticillata
Keratitis
Pain with instillation
Tearing

Role: adjunct.¹⁰
Efficacy: 25% to 30% IOP reduction¹⁰Most effective in patients with lower pre-treatment IOP (<25 mmHg).⁹
MOA: increased aqueous humor outflow³
Usual dosing frequency: once daily in the evening³
Discontinuation due to adverse effects greater than with timolol or latanoprost.¹⁰

Abbreviations: BAK = benzalkonium chloride; IOP = intraocular pressure

Wholesale acquisition cost (WAC) of generic, if available. US medication pricing by Elsevier, accessed February 2025.
Other sizes may be available.
Considerations for choosing an agent include cost, efficacy, side effects, comorbidities, patient preference, and dosing schedule.^1,10 If a single medication does not produce an adequate response, switch medication classes, or add another agent.^1,10 Additional efficacy is seen when agents with different mechanisms of action are used in combination.^8,10 Switching within a class can be tried to address adverse effects.¹⁰ Two or three medications may be required to achieve the desired IOP reduction.¹⁰ Counsel patients to wait three to five minutes between administration of different medications.¹⁰ Combination products may improve adherence and reduce eye exposure to preservatives.¹ To decrease systemic absorption, patients should be counseled to press on the bridge of the nose in the corner of the eye (i.e., nasolacrimal occlusion) during and for three to five minutes after administration, or close their eyes after administration.^1,8

References

Gedde SJ, Vinod K, Wright MM, et al. Primary Open-Angle Glaucoma Preferred Practice Pattern®. Ophthalmology. 2021 Jan;128(1): P71-P150.
Li T, Lindsley K, Rouse B, et al. Comparative Effectiveness of First-Line Medications for Primary Open-Angle Glaucoma: A Systematic Review and Network Meta-analysis. Ophthalmology. 2016 Jan;123(1): 129-40.
Clinical Pharmacology powered by ClinicalKey. Tampa (FL): Elsevier. 2025. http: //www.clinicalkey.com. (Accessed February 13, 2025).
Soltani G, Shalaby WS, Razeghinejad R. Latanoprostene bunod: the first nitric oxide-donating antiglaucoma medication. Med Gas Res. 2025 Jun 1;15(2): 220-227.
Vaajanen A, Vapaatalo H. A Single Drop in the Eye - Effects on the Whole Body? Open Ophthalmol J. 2017 Oct 31;11: 305-314.
Pratt NL, Ramsay EN, Kalisch Ellett LM, et al. Association between Ophthalmic Timolol and Hospitalisation for Bradycardia. J Ophthalmol. 2015;2015: 567387.
Stoner A, Harris A, Oddone F, et al. Topical carbonic anhydrase inhibitors and glaucoma in 2021: where do we stand? Br J Ophthalmol. 2022 Oct;106(10): 1332-1337.
Carey K, Hendricks BC. Eye disorders. In: Zeind CS, Carvalho MG, Cheng JWM, et al., editors. Applied Therapeutics: the Clinical Use of Drugs. 12th ed. Philadelphia, PA: Wolters Kluwer Health, 2024: 1183-1206.
Product information for Rhopressa. Alcon Laboratories. Fort Worth, TX 76134. September 2024.
American Optometric Association. Evidence-based clinical practice guideline. Care of the patient with primary open-angle glaucoma. First edition. Approved October 5, 2024. https: //www.aoa.org/a/19461. (Accessed February 20, 2025).

Cite this document as follows: Clinical Resource, Drugs for Open Angle Glaucoma.Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights.February 2025.[410271]

Drugs for Open-Angle Glaucoma

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